Rochester Area Collaborative Center Of Excellence In Pain Education

Instructional Manual

Morgan: A 14-year old girl with worsening headaches

Why are pain education teaching cases needed?

One of the major impediments to adequate relief of pain for patients of all ages is limited access to clinicians who are knowledgeable about managing acute and chronic pain. This problem was the focus of the Institute of Medicine's 2011 report, "Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research,"1 and was corroborated by the findings of the February 2012 Senate hearing entitled "Pain in America: Exploring Challenges to Relief."2 Because there are major gaps in knowledge about pain across health care and society alike, the IOM recommends that federal agencies and other stakeholders redesign education programs to bridge these gaps [http://www.nationalacademies.org/hmd/Reports/2011/Relieving-Pain-in-America-A-Blueprint-for-Transforming-Prevention-Care-Education-Research.aspx] . As a result of the IOM report, the Interagency Pain Research Coordinating Committee was asked to formulate a National Pain Strategy. Their report was released in 2016 [https://iprcc.nih.gov/National_Pain_Strategy/NPS_Main.htm].

Who created this case?

The clinicians who developed this case are an interprofessional group that includes physicians, nurses, pharmacists, a psychologist, an acupuncture/oriental medicine practitioner, a biofeedback specialist, a population health specialist, and two education specialists. All the health professionals are also experienced educators. Faculty members from 5 health care institutions participated in developing this case.

What are the guiding principles behind the design of this case?

  1. The Biopsychosocial Model of Dr. George Engel3 postulates that the person's state of health or wellness is the product of multiple aspects of an individual's being, including the physical or biological, the emotional or psychological, and the milieu or social environment in which he or she lives. This Biopsychosocial Model is the foundation of holistic, patient-centered care.
  2. Personalized care and self-management of pain. Because pain varies from patient to patient, healthcare providers should tailor pain care to each person's experience, and self-management of pain should be promoted. Focusing on the patient's own goals of care is particularly important in chronic pain management. Although a total "cure" may not be a realistic end point, enabling the patient to engage in the activities most important to his/her life goals may be achievable. Personalized care also integrates traditional and alternative modalities. Many patients seek and gain relief from self-selected approaches to pain control such as acupuncture or yoga or Reiki, and they often self-medicate for pain using herbal remedies, nutriceuticals and other agents that have the potential to interact with medications prescribed by physicians. There are increasing numbers of digital applications to help patients with self-management.4 It is therefore important for providers to encourage patients with chronic pain to discuss their self-management approaches, both to enhance treatment and to avoid unintended side-effects.
  3. The Core Competencies for Interprofessional Collaborative Practice were adopted by six national health professional associations in 2009 (www.aacn.nche.edu/education-resources/IPECR.pdf). The purpose of these competencies is to transform health care to provide collaborative, high quality, and cost-effective care for every patient. The four domains of core competencies emphasize patient-centered care; valuing the unique roles of interprofessional partners in caring for individuals and populations; communicating sensitively with patients, families, communities, and other health professionals; and working effectively as part of a collaborative health care team.5

What are the broad educational objectives of this case?

  1. Describe the diagnostic features of migraine in adolescent patients.
  2. Discuss the pathophysiology of migraine headaches in adolescents and relate to the present case.
  3. Discuss both pharmacologic and non-pharmacologic treatment strategies for migraine in an adolescent, using an integrative medicine approach.
  4. Discuss psychosocial, environmental, and lifestyle factors that may trigger or complicate treatment of migraine headaches.
  5. Demonstrate how to encourage active self-management in concert with ongoing provider care.

Note:Specific learning objectives in each discipline are included in the Case Map.

What are the main components of the case?

Description of patient case

  • Morgan is a ninth grader in a new school who has been suffering from more frequent (2/3 days/wk) and more severe headaches in the past 6 months. She has been visiting the school nurse's office frequently with severe headaches and the nurse has been sending her home. She is anxious about missing school, sports activities, and social events because of her headaches.
  • Morgan experienced cyclic vomiting when she was 5-7 years old. Six months ago, just before her headaches began to worsen, she suffered a concussion in a volleyball game. She is also feeling anxiety about being in a new school with many ongoing activities in softball, volleyball, music and drama, in addition to her school work, and she worries that the headaches are going to seriously disrupt these activities. She sleeps 6 hours per night and has frequent stomach aches.
  • Her mother has been giving her Excedrin Migraine, which she takes daily (1-2 doses). Occasionally, she has used her mother's Tylenol with codeine. She also drinks tea, and has energy drinks to "provide vitamins."
  • She complains of unilateral, right-sided temporal throbbing pain with sharp pain and feeling of fullness behind right eye. She reports feeling irritable the day prior to migraine onset. Headaches are preceded by tingling sensation in her fingers and at times, and she has trouble "getting the words out." Headaches are often associated with her menstrual periods.
  • Her PCP refers her to a neurologist, who diagnoses her with migraine headaches, likely exacerbated by medication overuse and anxiety. Her anxiety may well be increased by her mother's concern about her headaches.
  • Recommended treatment includes discontinuation of OTCs, and taking Amitriptyline and Migrelief, in addition to rizatriptan (Maxalt) at onset of a headache. She is advised to eliminate caffeine use, eat breakfast without fail and then small meals throughout the day, maintain a routine schedule of sleeping, and avoid overscheduling. The school nurse is educated to help Morgan manage her attacks without going home from school, using preventive medication and rest.
  • She is referred to a psychologist for anxiety reduction and relaxation therapy. Other possible interventions that she might try are acupuncture, biofeedback, or other alternative therapies.

Presentation of the Core Case. The patient is presented through a combination of videotaped phone conversations and patient vlogs, plus video clips of interactions with providers that are portrayed by standardized patients and live clinicians (see Case Map, below). The video clips of the patient encounters are generic enough that learners in multiple health care professions should be able to benefit from them. Video clips are interspersed with slides that teach content needed to understand the case, such as how to assess pain and what drugs are being used to treat Morgan's migraines. Pertinent questions are included to reinforce learning.

This educational curriculum is created to be flexible, so it can be organized to fit course and learner needs. Some instructors may want to lead an introductory discussion to create a foundation of knowledge before learners view the case. Others may prefer to use the case as a springboard for further learning.

As described in more detail in the Case Map, the core case includes the following events, which are staged over a 4 month period:

  • Stage 1 (9/2 to 11/26) : How worsening headaches are affecting Morgan's life and health
  • Stage 2 (11/27 to 11/28): Visit with Nurse Practitioner and Neurologist; education by Pharmacist; coordination of treatment plan with School Nurse
  • Stage 3 (12/01 to 1/2) : Alternative therapies: Visits with Psychologist, Acupuncturist, and Biofeedback Specialist
  • Stage 4 (1/13 to 1/17): Effects of treatment and follow-up with Neurologist

We begin the case with six Study Questions (listed below) that will help students to frame their thinking about the case. These questions may also be useful for class discussion after a group of students has completed the case.

Study Questions for the Adolescent Headache Case

  1. What are special considerations for treatment of an adolescent with migraines, compared to an adult?
  2. What lessons about self-medication does this case teach?
  3. What migraine triggers should be considered in creating a management plan?
  4. How can the patient collaborate in managing her headaches?
  5. How does the patient's anxiety affect her symptoms and relate to her treatment?
  6. Why is non-pharmacologic treatment recommended in addition to treatment with medications?

Supplementary didactic materials. Teaching materials to supplement Morgan's case include both slidesets within the case and links to "Learn More" resources. Learn More topics (found on the right side bar) include

  1. Acupuncture: Definition, how it works, acupuncture in headaches, evidence for effectiveness, referral
  2. Biofeedback: What are pain and anxiety, why distraction/engagement works, what is biofeedback
  3. Cognitive Behavioral Therapy: What is CBT, how does it work (targeting thoughts, feelings, behaviors), use of CBT, referral
  4. Insurance and Migraine Therapies: Cost-effectiveness of Cefaly (TENS) vs Metroprolol vs BOTOX, how to manage insurance value, medications with limited evidence regarding value
  5. Migraine Treatment: Goals of therapy, non-pharmacologic approaches, drug treatment options and dosage forms, mechanisms of action, medications used for migraine prophylaxis
  6. Pathophysiology of Migraine: Common migraine triggers, pathophysiology of migraine, role of serotonin and CGRP in migraine, features of migraine with aura, migraine variants seen in children
  7. Pharmacology of Morgan's Prescriptions: Amitriptyline and Rizatriptan, serotonin syndrome, other medications and supplements used for treatment and prophylaxis, communicating with children and parents about medications, talking to adolescents
  8. Role of the Community Pharmacist in Patient Education: Counseling patients about self-care, when NOT to self-treat for headaches
  9. Self-Care Apps and Digital Resources: How to support an adolescent in use of digital self-management technologies, privacy issues related to using web-based or wearable technologies or apps, factors affecting adolescents technology use, choosing among tools available

Student assessment. Because this teaching case is designed for use by a variety of interdisciplinary learners, we have included in the case only questions of a general nature that all health care practitioners might be expected to answer. The primary purpose of these questions is to stimulate curiosity and reinforce learning as learners work through the case. We expect that course directors using the case will want to create discipline-specific questions for use with nursing, medicine, pharmacy, psychology, and acupuncture/oriental medicine students.

How can instructors use this case?

The case, in a nutshell, focuses on approaches to managing life-disrupting migraine headaches in an adolescent patient. Encouraging the patient to participate in her own care, with her mother's support, is important, because eating, sleeping and other lifestyle changes will enhance her recovery. In addition, a collaborative approach to care among traditional and alternative providers is useful, since controlling anxiety and stress is a key element of migraine relief for this patient, who leads a very active life with many commitments and high standards for performance. Hence the case is a good example of both team-based, interprofessional care and sensitive patient education to enhance self-management.

The case is programmed for flexible use, which might include 1) online self-study by early to more advanced learners from different disciplines, or 2) use of the case to enhance teaching in the classroom setting. The video clips may be used to:

  • Introduce the case history, which can be watched by a group and followed by discussion
  • Embed in a lecture or formal case presentation, e.g., as a demonstration of how different health professionals approach this patient
  • Assess students (e.g., testing decision making around management of patient care)

The Case Map will help instructors choose components of the case that best meet their teaching goals and learners' needs. We suggest four possible approaches:

  • Introducing learners to the roles of clinical providers in different disciplines
  • Describing and discussing specific patient care techniques
  • Discussing approaches to enable self-management by the patient and family
  • Use of Learn More materials for learning enrichment

Professional roles that are portrayed in the case include the:

  • Neurologist
  • Nurse Practitioner
  • School Nurse
  • Pharmacist
  • Psychologist
  • Acupuncturist
  • Biofeedback specialist

Any of these roles could be taught using the video clips within the case, plus accompanying teaching slide sand Learn More materials. For example, the Learn More segment on Acupuncture includes videos of needling techniques with explanations and cautions. The Case Map will help instructors find discipline-specific clips and information.

Specific patient care techniques that are demonstrated in the video clips include how to:

  1. Conduct a sensitive history
  2. Educate patient about her migraines, including risk factors and triggers to avoid
  3. Discuss self-management approaches to control migraine episodes
  4. Educate patient/mother about proper use of medications and their potential side effects in a sensitive manner with language a patient can understand
  5. Guide a school nurse to help a patient self-manage migraine episodes in school
  6. Describe goals of cognitive behavioral therapy to a patient and family
  7. Help a patient understand the thoughts, feeling, and behaviors that accompany and exacerbate anxiety
  8. Teach a patient to do relaxation therapy
  9. As an acupuncture specialist, conduct exam and plan treatment for migraines
  10. Conduct biofeedback session to assess the effectiveness of various relaxation techniques for this patient
  11. Reassess pain symptoms and patient's response to treatment
  12. Discuss progress with self-management strategies and encourage continuation
  13. Discuss with patient long term prognosis and future treatment

The Case Map shows how these patient care techniques fit into the Stages of Care 2-4.

Didactic content. Learn More resources, which include informational slides, videos, links and publications, are listed below and can be accessed online on the right side bar. These may be selected by learners as they proceed through the case, or assigned by instructors. Instructors may wish to use the additional resources offered in the case to teach about specific topics that are integral to understanding Morgan's condition and how it may be managed (e.g., pharmacology of her medications). Learn More resources are listed and described above under Supplementary didactic materials

Cited References

  1. Pizzo PA, Clark NM. Alleviating Suffering 101 - Pain relief in the United States. The New England Journal of Medicine 2012;366(3):197-9.
  2. Moore D. Senate Panel Explores IOM Recommendations on Pain. 2-17-2012. Ref Type: Internet Communication
  3. Engel G. The need for a new medical model: A challenge for biomedicine. Science 1977;196(4286):129-36.
  4. Minen M, Torous J, Raynowska J, Piazza A, Grudzen C, Powers, S, Lipton R, Sevick M. Electronic behavioral interventions for headache: a systematic review. The Journal of Headache and Pain, May 2016, Vol.17, pp.1-20.
  5. Interprofessional Education Collaborative Expert Panel. Core competencies for interprofessional collaborative practice: Report of an expert panel. 2011.

Case Map

Morgan: A 14-year old girl with worsening headaches

Overall Educational Goals:

  1. Describe the diagnostic features of migraine in adolescent patients.
  2. Discuss the pathophysiology of migraine headaches in adolescents and relate to the present case.
  3. Discuss both pharmacologic and non-pharmacologic treatment strategies for migraine in an adolescent, using an integrative medicine approach.
  4. Discuss psychosocial, environmental, and lifestyle factors that may trigger or complicate treatment of migraine headaches.
  5. Demonstrate how to encourage active self-management in concert with ongoing provider care.

Note: For each of the 4 stages of the case, a summary of learning points and learning objectives are provided.

Stage 1 (9/2 to 11/26) : How worsening headaches are affecting Morgan's life and health

Important factors in patient history:

Effect of headaches on:
  • social life
  • athletics
  • academic work
  • relationship with mother
Anxiety in an over-scheduled teen

Mom's treatment of Morgan with OTC analgesics

Morgan's use of mom's Rx medicine
Patient's Story: Problems at Home and at School
Patient's Story: Decision to seek medical help
Key Issues
  • Missed social events
  • Missed volley ball practice
  • Problems in class
  • Morgan's increasing anxiety with interference of headaches with her life
  • Mother's stress, empathy with Morgan given her own migraine history
  • Self-medication: Excedrin Migraine + Rx pills from Mom's purse
  • No more Excedrin--Morgan's frustration, anger with mom, guilt about stealing Rx meds
Deciding Factors
  • Guidance from community pharmacist: Excedrin may be making headaches worse
  • Possible diagnosis of migraine, confirming mom's fears
  • Morgan's state of distress; Mom's sense of guilt and anxiety


Stage 2 (11/27 TO 11/28): Visit with Nurse Practitioner and Neurologist; education by Pharmacist; coordination of treatment plan with School Nurse

Demonstrated Patient Care Techniques:
  • Conduct a sensitive history
  • Educate patient about her migraines, including risk factors and triggers
  • Explain Rx use for prevention and treatment
  • Discuss self-management approaches
  • Guide a school nurse in helping a patient self-manage migraine episodes
  • As pharmacist, educate patient/mother about proper use of meds and potential side effects
Visit to Nurse Practitioner (NP)
Visit to Neurologist
Telephone call from NP to school nurse
Talk with Community Pharmacist
Headache History:
  • Medical history
  • Family history
  • Psychologic stressors
  • Headache characteristics
  • Pain assessment
  • Medication use
Discussion:
  • Symptoms review, Dx of migraine
  • Review of potential triggers
  • Recommended therapies (pharm and non-pharm)
  • Avoidance of triggers
  • Relaxation methods
  • Referrals to psychology, acupuncture, biofeedback
Chart Note:
Example of a complete note from a specialist to the referring physician.

Learn More:
  • Migraine Treatment: goals of therapy, non-pharm approaches, drug Tx options, mechanisms of action, meds used for prophylaxis
  • Pathophysiology of Migraine: Common triggers, pathophysiology, role of serotonin and CGRP, features of migraine with aura, variants seen in children
Discussion:
  • Patient information
  • Symptoms
  • Current management plan
  • Recommended management in school setting
Discussion:
  • Symptoms
  • Current meds in use
  • Med overuse headaches
  • Recomm to visit MD for possible Dx of migraine
Learn More:


Learning Objectives for Stage 2

Neurology

  1. Discuss the diagnosis of migraine based on Morgan's history and differentiate migraine from other headache types.
  2. Recognize "red flag" findings in Morgan's exam and historical details.
  3. Identify common migraine triggers and how they may be minimized.
  4. Describe both pharmacologic and non-pharmacologic strategies for migraine treatment that would be suitable for Morgan.
  5. Identify confounding headache factors and barriers to treatment (e.g., medication misuse or overuse, psychosocial stressors, environmental circumstances).

Pain Pathways

  1. Describe the anatomy and physiology associated with normal sensory transmission.
  2. Describe the pathophysiology associated with migraine.
  3. Describe how the physiology of migraine variants seen in children may differ from that of migraines seen in adults.

Pharmacology

  1. Describe the mechanisms of action of the medications prescribed for Morgan, including rizatriptan (Maxalt) and amitriptyline.
  2. Discuss the consequences of Morgan's overuse of Excedrin Migraine, based on its mechanism of action.
  3. Describe the components of Migrelief and how they may contribute to alleviation of migraine symptoms.
  4. Explain the important differences between the metabolism of medications in adolescents, compared to adults.

Population Health

  1. Describe factors affecting the use of digital technology among patients with adolescent migraines, including prevalence and availability.
  2. Delineate the privacy issues about using web-based or wearable technologies or apps self-management of migraine.
  3. Explain the evidence supporting the use of step therapy and stopping rules for Botox insurance coverage.
  4. Identify at least one resource for new information about the value (relative cost and effectiveness) of migraine treatments.  

Nursing (school nurse education)

  1. Accurately assess migraine symptoms in a student.
  2. Discuss a number of acute treatment options in the school setting, as outlined in a student's Headache Management Plan.
  3. Explain when a student with migraine symptoms can remain in school and when he/she needs to be sent home.

Pharmacy

  1. List evidence-based medication therapy appropriate for the acute and prophylactic treatment of child/adolescent migraines.
  2. Assess a patient's ability to manage self-care, recommend an appropriate course of action based on described symptoms, and advise on need for professional medical advice if self-medication is inadequate.
  3. Describe how to counsel an adolescent about pharmacologic treatment for migraines in keeping with her level of health literacy.

Stage 3 (12/01 to 1/2) : Alternative therapies-- Visits with Psychologist, Acupuncturist, and Biofeedback Specialist

Demonstrated Patient Care Techniques:
  • Describe goals of CBT
  • Discuss self-management of migraine episodes
  • Discuss anxiety control
  • Teach patient to do relaxation therapy
  • As an acupuncture specialist, conduct exam and plan treatment for migraines
  • Conduct biofeedback session with patient to assess likelihood that relaxation therapy will be effective
Visit to Psychologist
Visit to Acupuncturist
Biofeedback session
Discussion/Patient Education
  • Review of headache diary
  • Interconnected thoughts, feelings, behaviors that accompany headaches
  • Using guided imagery to relax
Management:
  • Headache diary
  • Relaxation therapy
  • Behavioral techniques
  • Cognitive techniques
Learn More:
Evaluation:
  • Targeted history
  • Physical exam: pulses, tongue, abdomen
Findings
  • Concussion and blood statis (reduced perfusion)
  • Liver depression
  • Acupuncture may help
Discussion:
  • How acupuncture is done
  • Does it hurt?
  • Treatment planning
Learn More:
  • Acupuncture: Definition, how it works, acupuncture in headaches, evidence for effectiveness, referral
Discussion:
  • Brief history
  • Definition and explanation of biofeedback
  • Nerves and pain perception
  • Finger temperature affected by stress and relaxation
  • Using biofeedback to choose and optimize an effective relaxation method
Learn More:
  • Biofeedback: What are pain and anxiety, why distraction / engagement works, what is biofeedback?


Learning Objectives For Stage 3

Behavioral Health

  1. Identify signs and symptoms that indicate need for a referral to behavioral health.
  2. Explain how Morgan's avoidance behaviors may maintain her anxiety symptoms.
  3. Name one cognitive and one behavioral strategy from CBT used to treat Morgan.

Acupuncture

  1. Describe the outcomes Morgan might expect from acupuncture in terms of mental health, pain and overall wellness.
  2. Briefly discuss the evidence for the suitability of acupuncture as an intervention for Morgan, the primary criteria for selecting interventions, and strategies for prioritizing these criteria.
  3. Describe a typical acupuncture assessment, including history, assessment, and physical exam.
  4. Describe the use of pattern diagnosis, channel theory and palpation.
  5. Describe how to find an acupuncture specialist and write a referral, including rationale and typical duration of treatment.

Biofeedback

  1. Define biofeedback and describe its administration.
  2. Describe how biofeedback might work to relieve Morgan's pain and/or stress.
  3. Explain changes in finger temperature induced by stress and relaxation.

Stage 4 (1/13 to 1/17): Effects of treatment and follow-up with Neurologist

Important factors in patient response to treatment:
  • Medications and relaxation appear to be reducing headaches
  • School management of headaches is keeping her at school
  • Morgan plans to continue self-relaxation exercises
  • Morgan has less anxiety and is doing better at home and school and in athletics
Morgan's story as treatment progresses
Followup with Neurologist
Summary
  • Morgan had only 1 headache in the past week
  • Plans to continue relaxation exercises
  • Willing to consider acupuncture and biofeedback if needed
  • She is happy about school management of her headaches
  • Coach reports improvement at volley ball practice
  • Mom is pleased with Morgan's progress
Discussion:
  • Review of Tx plan implementation in home and school
  • Review of response to Tx with reinforcement
  • Plan for follow up, what to expect in future
Learn More:
  • Self-Care Apps and Digital Resources: How to support an adolescent in use of digital self-management technologies, privacy issues related to use of web-based or wearable technologies or apps, factors affecting adolescents technology use, choosing among tools available


Learning Objectives For Stage 4

Goal 5. Demonstrate how to encourage active self-management in concert with ongoing provider care.

Study Questions for the Adolescent Headache Case

  1. What are special considerations for treatment of an adolescent with this condition, compared to an adult?
  2. What lessons about self-medication does this case teach?
  3. What migraine triggers should be considered in creating a management plan?
  4. How can the patient collaborate in managing her headaches?
  5. How does the patient's anxiety affect her symptoms and relate to her treatment?
  6. Why is non-pharmcologic treatment recommended in addition to treatment with medications?